Preferred Care at Home of National Headquarters | 354 NE 1st Ave Delray Beach, Fl 33444 

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Transition Care

Personal patient coaching to reduce readmissions


Since Medicare announced it will penalize hospitals that have high readmission rates, facilities have been scrambling to reduce them. The problem is, much of the readmission risk is tied to poor transition care and notably the patient’s home circumstances.

Download our hospital-to-home brochure written specifically for you

Elderly people in particular often don’t have a consistent support system. With no one to help them through a confusing transition care process and encourage them as they recover at home, it’s no wonder they’re at high risk for readmission. In fact, on average, if you discharge five Medicare patients from a hospital today, at least one will check back in within a month. Thirty-four percent will be back within 90 days.

At Preferred Care at Home, we decided to tackle this transition care problem head-on. We delved into the scientific literature and identified primary readmission causes. We examined solutions that were starting to work. Then, we became one of the first in-home care companies in the country to develop a transition care coaching service. We call it Smooth-Transition Care.


Smooth-Transition Care:

4 Solutions to Prevent Readmission

Smooth-Transition Care, an affordable, evidence-based service, combines four key components to prevent readmission in elderly people:

1. Hospital-to-home coaching

One of the biggest readmission causes is poor communication with the patient and even between the health care providers. This often happens during the discharge process. In Smooth-Transition Care, a personal coach guides the elderly patient through transitions. The patient also receives a needed organizational tool where all recovery instructions are kept in one place.

2. Home-recovery coaching

After discharge, this same personal coach meets with the senior regularly to encourage and support. For example, the coach arranges transportation to follow-up appointments and makes sure prescriptions are taken and that the home is safe.

3. Organized medical instructions

The coach encourages the senior to use the Personal Health Record, our 15-piece organization tool kit. Along with serving as a thorough health-history tool, the Record addresses four main causes of readmission. It combats poor medication management and missed follow-up appointments through sections with detailed instructions. It provides tips to prevent falls. And it fights lack of education about chronic disease: An easy-to-read chart tells which symptoms require immediate attention and which ones your regular doctor can take care of. This helps prevent unnecessary emergency-room visits.

4. Online health records

Upon the client’s request, the coach attaches the Personal Health Record to a secure online database. With a password, doctors can view information from all the senior’s other providers, including pending tests and scheduled appointments. Family members can easily access up-to-date instructions and appointment dates.


Evidence-Based Readmission Prevention

In a randomized, controlled trial of a program from the University of Colorado, Denver, that was similar to Smooth-Transition Care, patients in the program had a 30-percent lower rehospitalization rate at 30 days than those who had no transition care. By 180 days, 38 percent fewer patients had been readmitted for the same diagnosis they were originally hospitalized for.

At Preferred Care at Home, we want to partner with you to improve senior care. Together, as leaders in the care industry, we’ll set a new transition standard. Please give us a call. We’re eager to share ideas on how we can work together to make seniors’ lives better.

If you’d like to suggest our services to your patients, we’d love to talk with them about their needs as well—and offer them a free download of the Personal Health Record.

For a more in-depth look at how we help facilities such as hospitals and nursing homes prevent readmission in elderly people—and to check out the sources that support our findings—please click here to download our health care providers brochure.
At Preferred Care at Home, we want to partner with you to improve senior care. Together, as leaders in the care industry, we’ll set a new transition standard. We’re eager to share ideas on how we can work together to make patients’ lives better. If you would like to suggest our services to your patients, we’d love to talk with them about their needs as well—and offer them a free download of the Personal Health Record. We look forward to creating compassionate, affordable, effective, evidence-based transition solutions.

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